Publications

We present a case of a patient with undiagnosed myasthenia gravis presenting in myasthenic crisis. In this case, the patient presented primarily with myocardial infarction with nonobstructive coronary arteries and respiratory failure and was later diagnosed to be in myasthenic crisis. The myasthenic crisis was treated with intravenous immunoglobulin (IVIg) and corticosteroids. Given the inadequate response to IVIg and glucocorticoids, the patient was subsequently administered an anti-CD20 monoclonal antibody in the form of rituximab. The patient responded well to rituximab, and her cardiac function subsequently improved.

INTRODUCTION: Our study assesses human immunodeficiency virus (HIV) drug resistance (HIVDR) in patients failing first-line (1L) antiretroviral therapy (ART) with dual nucleoside analog reverse transcriptase inhibitor (NRTI) and non-nucleoside reverse transcriptase inhibitor (NNRTI) regimens in India.

METHODS: In this cross-sectional study, consecutive HIV-1-infected patients aged 13 years or older, failing 1L ART after at least 12 months exposure, underwent HIV genotyping and drug resistance testing (DRT) using the ViroSeq™ HIV-1 Genotyping System and the Stanford HIV-1 Database, with HIVDR classification based on a penalty score of ≥30.

RESULTS: Among 115 eligible participants, 110 underwent DRT, revealing efavirenz (EFV) or nevirapine (NVP) resistance rates of 85.3% (n = 93/109) and 87.2% (n = 95/109), respectively, and substantial cross-resistance to rilpivirine (RPV) (37.6%, n = 41/109), etravirine (ETV) (30.3%, n = 33/109), and doravirine (DOR) (60.5%, n = 66/109). The cohort was categorized into 3 groups based on their previous ARV drug exposure: group A (36.4%, n = 40) with prior TA exposure (AZT or d4T) but no TFV exposure; group B (19.1%, n = 21) with prior nonconcomitant exposure to both TAs and TFV; and group C (44.5%, n = 49), exposed to TFV only. Despite group B's 1L ART regimen failure with TFV, the prevalence of AZT resistance was similar (difference in proportions, ∇P: 14.6%, p = 0.277) between group A [57.5% (n = 23/40)] and group B [42.9% (n = 9/21)]. TFV resistance was comparable (∇P: 0.8%, p = 0.947) between group A (32.5%, n = 13/40) and group B (33.3%, n = 7/21), despite group A's lack of TFV exposure, and was also similar to the TFV-only-exposed group (group C: 38.8%, n = 19/49). Regarding distinct DRM patterns, the prevalence of K65R DRM was higher (∇P: 22.4%, p = 0.060) among TFV-only-exposed patients (group C: 36.7%, n = 18/49) compared with PLH exposed to both TAs and TFV (group B: 14.3%, n = 3/21), whereas multiple TAMs occurred at similar rates (∇P: 12.1%, p = 0.367) among TA-exposed patients [group A: 55.0% (n = 22/40) vs group B: 42.9% (n = 9/21)].

CONCLUSION: The research provides insights into the complexities of HIVDR, emphasizing the interplay of resistance patterns and the role of drug exposure history, especially in the context of resistance to TFV and second-generation NNRTIs.

CLINICAL SIGNIFICANCE: Ensuring adequate drug exposure history in patients can prevent poor outcomes in PLH being treated with ART due to resistance. Resistance profiling is especially relevant following first-line ART failure.

OBJECTIVE: Risk estimation tools have been developed to predict coronary heart disease (CHD) in type 2 diabetes (T2D). To evaluate augmentation following the addition of lipoprotein(a) [Lp(a)] to risk calculation, we performed a pilot study.

METHODS: A total of 90 successive T2D patients were included. Details of clinical and biochemical features were obtained. Lp(a) was determined using ELISA. CHD risk estimation was performed using Framingham, QRISK-3, SCORE-2D, INTERHEART, and European Atherosclerosis Society (EAS) algorithms with and without Lp(a). Descriptive statistics are reported.

RESULTS: Mean age of patients was 55.0 ± 8 years, BP systolic/diastolic 133.7 ± 12/95.0 ± 9 mm Hg, body mass index (BMI) 26.0 ± 1.9 kg/m2, waist-hip ratio 0.96 ± 0.08, fasting glucose 198.0 ± 38 mg/dL, HbA1c 9.3 ± 1.3%, total cholesterol 197.0 ± 26 mg/dL, LDL cholesterol 114.2 ± 25 mg/dL, non-HDL cholesterol 153.8 ± 27 mg/dL, and triglycerides 197.8 ± 44 mg/dL. Lp(a) was mean 23.1 ± 9.7 mg/dL and median 22.0 (25-75 IQR 15.9-29.5) mg/dL. Mean risk scores were Framingham 11.2 ± 8.7, QRISK-3 28.6 ± 15.3, INTERHEART 21.0 ± 6.0, SCORE-2D 14.9 ± 8.3, and EAS 29.2 ± 15.2. Patients with raised Lp(a) >30 mg/dL had higher levels of total, LDL, and non-HDL cholesterol and triglycerides (p < 0.01). Spearman's correlation of Lp(a) with risk scores was Framingham 0.127, QRISK-3 0.174, INTERHEART 0.137, SCORE-2D 0.050, and EAS 0.320, while EAS-Lp(a) was 0.397. In different risk algorithms, high risk for CHD were: Framingham 14.4%, QRISK-3 64.4%, INTERHEART 45.6%, SCORE-2D 30.0%, EAS 71.1%, and EAS with Lp(a) 74.4%. Area under the curve (AUC) for Lp(a) with various scores were Framingham 0.53 (CI: 0.39-0.68; p = 0.644), QRISK-3 0.57 (CI: 0.42-0.71), INTERHEART 0.55 (CI: 0.39-0.69), SCORE-2D 0.47 (CI: 0.32-0.61), EAS 0.65 (CI: 0.50-0.79), and EAS-Lp(a) 0.68 (CI: 0.54-0.83). In addition, adding Lp(a) to the EAS risk calculator increased risk reclassification by a range of 4.6-19.3%.

CONCLUSION: Substantial variation in coronary artery disease (CAD) risk prediction using various clinical algorithms is observed in T2D. The EAS algorithm provides the most robust estimate. The addition of Lp(a) to the risk algorithms augments risk stratification significantly. The results of this pilot study need confirmation with larger prospective studies.

BACKGROUND: Tropical coinfections (CI) are the simultaneous occurrence of two or more vector-borne diseases in a single host. The prevalence of such illnesses is not uncommon among tropical and subtropical regions such as India; however, these CIs have not been systematically studied prospectively. Mixed infections can prove potentially detrimental if underdiagnosed or undertreated. We undertook this study to estimate the prevalence and compare the clinical profile, laboratory characteristics, and various outcomes among the patients with tropical CI who presented with acute undifferentiated febrile illness (AUFI).

MATERIALS AND METHODS: A prospective, observational study was conducted on adult patients hospitalized with tropical CIs. As per the clinical suspicion, a panel of tests for dengue fever (D), malaria (M), scrub typhus (S), leptospirosis (L), chikungunya (C), and brucella (B) was carried out. Statistical analysis was done using standard methods.

RESULTS: The mean age of the population was 39.4 ± 17.3 years. Among 986 patients presenting with AUFI, 8.1% of the patients had CIs. Of these CIs, 95% had dual infections, and 5% had CIs with three tropical pathogens. We observed 17 diverse tropical CI combinations; four predominant being D + L, D + S, D + C, and S + L with a prevalence of 26.2, 25, 15, and 13.8%, respectively. 16.25% of the patients with tropical CIs died, mostly those suffering from D + S and D + L. Coinfection with D + S had predominant acute kidney injury (AKI), whereas acute transaminitis was highest in the D + L category. Acute respiratory distress syndrome (ARDS) was clinically significant in S + L, and multiorgan dysfunction was highest in the D + S combination. Using logistic regression, AKI, hepatitis, ARDS, shock, gastrointestinal bleeding, and myocarditis were independent risk factors for mortality.

CONCLUSION: Our study identified 17 different combinations of CIs. Four groups, i.e., D + L, D + S, D + C, and S + L-accounted for 80% of CIs. Despite significant organ involvement in certain CI combinations, we conclude that a clinical bedside differentiation of tropical CIs from monomicrobial infections is often difficult. Hence, optimal treatment for a possible CI may well be commenced empirically and early, bearing in mind an 8% probability of a concurrent tropical coinfection.

BACKGROUND: Osteoporosis, a common bone disease among postmenopausal women, where bone is weak by diminished bone mineral density (BMD), increasing the fracture risk. Our body's natural rhythm, called the "circadian rhythm," which is controlled by the brain and body, helps in bone formation and also in breakdown, disruption of this rhythm may affect bone health. This study explores how problems with circadian rhythm might be linked with osteoporosis in postmenopausal women.

OBJECTIVE: To assess the prevalence of osteoporosis among postmenopausal women and to see if it is related to changes in their body's daily sleep-wake cycle, "circadian rhythm," using a composite morningness-eveningness questionnaire (CMEQ) that groups people as morning, evening, or in between types.

MATERIALS AND METHODS: This cross-sectional observational study was conducted at Swaroop Rani Hospital, Prayagraj, India, between March 2024 and March 2025. This study included 109 postmenopausal women after applying strict inclusion/exclusion criteria. Each woman underwent clinical evaluation, anthropometric measurements, and biochemical testing. BMD by dual-energy X-ray absorptiometry (DEXA) scan at the lumbar spine with right and left femoral necks. To understand their sleep-wake pattern, "circadian rhythm" participants filled out a special questionnaire called the CMEQ, which groups them as morning, evening, or in between types. Data was analyzed using computer software (SPSS v25.0) to find patterns and differences.

RESULTS: The prevalence of osteoporosis was 32.1% (35 among 109 women). Osteoporotic women had significantly lower weight (58.1 ± 11.63 vs 64.3 ± 13.65 kg; p = 0.023) and height (149.1 ± 7.12 cm vs 153.0 ± 7.08 cm; p = 0.008) compared to nonosteoporotic participants. Body mass index (BMI) was lower in the osteoporotic group (26.3 vs 28.1), though not statistically significant (p = 0.093). The mean composite M-E score did not have a significant value between osteoporotic and nonosteoporotic groups (44.8 ± 3.55 vs 44.6 ± 4.23; p = 0.852), indicating no significant association between circadian rhythm and osteoporosis.

CONCLUSION: About one-third of postmenopausal women in the study had osteoporosis. Although anthropometric differences were significant, no statistical significance was found between circadian rhythm and BMD. The findings suggest that circadian rhythm may affect bone health, but the questionnaires CMEQ used in this study may not be the best way to measure it. Future studies should use more accurate measures of taste, such as circadian hormone levels, and follow people over time to better understand this relationship.

INTRODUCTION: Diabetic retinopathy (DR) is the most important risk factor causing blindness in diabetic individuals, and its risk progresses with increased disease duration. Epicardial fat thickness (EFT) is an emerging indicator of inflammation and metabolic derangement and has been proposed as a potential biomarker linked to the severity of DR. This study aims to assess the prevalence of DR, identify risk factors associated with DR, and evaluate the predictive role of EFT in detecting DR in subjects with type 2 diabetes mellitus (T2DM).

METHODS: A cross-sectional observational study was conducted at LLRM Medical College, Meerut, from 2023 to 2024. The participants included 130 T2DM patients who were assessed clinically, radiologically, and biochemically. Demographic data, duration of diabetes, body mass index (BMI), HbA1c levels, and EFT were measured. The severity of DR was determined based on ophthalmic examination. Data were analyzed using Kruskal-Wallis and Chi-squared tests.

RESULTS: In this study of 130 patients with T2DM, 64.61% (n = 84) had DR, including 33.84% (n = 44) with nonproliferative DR (NPDR) and 30.76% (n = 40) with proliferative DR (PDR), while 35.38% (n = 46) had no DR. Patients in the PDR group were older on average (60.5 ± 13.9 years), but age differences were not statistically significant (p = 0.154). The duration of diabetes was significantly longer in PDR patients (9.0 ± 3.01 years) compared with NPDR and non-DR groups (p < 0.001). BMI increased with DR severity, reaching 28.49 ± 2.07 kg/m2 in the PDR group, in which 20% were obese and 72.5% were overweight. A higher waist-hip ratio (WHR) was significantly associated with more severe DR in males (p < 0.001) but not in females (p = 0.099). HbA1c levels increased with disease severity, from 6.1 ± 0.71% in non-DR to 8.6 ± 1.97% in PDR patients (p < 0.001). Similarly, EFT increased from 3.9 ± 0.47 mm in non-DR to 7.9 ± 1.09 mm in PDR (p < 0.001), suggesting EFT as a potential biomarker for DR severity. These findings highlight strong links between DR severity, poor glycemic control, obesity measures, and longer diabetes duration.

CONCLUSION: These findings suggest that in type 2 diabetes mellitus patients, EFT can serve as a significant marker for the severity of DR. It can be used as a noninvasive investigation to predict PDR. When considered alongside established risk factors such as BMI, HbA1c levels, and diabetes duration, EFT could enhance early identification of patients at risk, potentially helping to prevent advancement to the more severe proliferative stage (PDR). However, larger and more extensive studies are required to confirm these observations and strengthen their clinical relevance.

We report a case of a 22-year-old male who was previously treated for asthma from childhood, and his repeated respiratory infections prompted the physician to start antitubercular therapy (ATT) thrice, suspecting pulmonary tuberculosis despite being sputum acid-fast bacillus (AFB) negative every time. Diagnosis of Kartagener syndrome (autosomal recessive inheritance having a triad of bronchiectasis, chronic sinusitis, situs inversus, and strongly associated with infertility) was made in this case at our tertiary care referral hospital, but it was already too late when he presented with life-threatening bilateral pneumonia, bilateral pleural effusion with type II respiratory failure, and associated cystitis warranting mechanical ventilation, and he succumbed because of extremely and irreversibly damaged lungs.

BACKGROUND: Metformin has been the cornerstone of type 2 diabetes mellitus (T2D) pharmacologic management, but gastrointestinal (GI) intolerance limits its use in a significant subset of patients. In India, alternative therapies for metformin-intolerant subjects are needed given the high diabetes burden and early disease onset. Imeglimin, a novel oral antidiabetic agent with a distinct mitochondrial mechanism of action, has shown efficacy and tolerability but lacks large real-world evidence in Indian subjects unable to tolerate metformin.

MATERIALS AND METHODS: This 6-month, prospective, multicenter, observational study was conducted across 19 clinical sites in India to evaluate the effectiveness and safety of imeglimin in a real-world setting. The study population comprised adult patients with T2D who were identified as intolerant to metformin. Following enrollment, subjects were initiated on treatment with imeglimin, administered either as monotherapy or as add-on therapy to existing regimens. The primary effectiveness endpoint was the change from baseline in glycated hemoglobin (HbA1c) at 6 months and the assessment of safety and tolerability.

RESULTS: Among the 722 analyzed subjects, the mean age was 53.1 years, and the mean baseline HbA1c was 8.5%. Imeglimin therapy produced sustained improvements: Mean HbA1c decreased by 1.26% at 6 months (p < 0.001). Imeglimin performed well as both monotherapy (reduction of 0.77% at 6 months, p < 0.001) and combination therapy [with two oral antidiabetic drugs (OADs), a reduction of 1.15%, p < 0.001; and with three or more OADs, a reduction of 1.86%, p < 0.001]. The treatment was well tolerated, with no serious adverse events reported. Overall, 29.7% of participants experienced side effects, most commonly GI symptoms (15.3%), followed by urinary or genital tract infections (5.0%), nausea or vomiting (5.1%), headache (7.1%), and hypoglycemia (1.1%).

CONCLUSION: Imeglimin demonstrates clinically meaningful glycemic efficacy in a real-world setting among metformin-intolerant patients. Its high efficacy, even in complex combination regimens, combined with a favorable safety profile and a low risk of hypoglycemia, establishes imeglimin as a highly valuable and effective alternative for patients who cannot tolerate metformin.

BACKGROUND: Universal health coverage (UHC) and primary health care (PHC) are critical components of equitable health systems. Medical and allied health science students, as future healthcare providers, need to possess knowledge and understanding of these concepts. Educational interventions are pivotal in enhancing this knowledge and preparing students for effective healthcare delivery.

OBJECTIVES: This study aimed to assess the impact of an educational intervention on the knowledge and perception of UHC and PHC among healthcare students at a private medical university in north Karnataka.

METHODOLOGY: A quasi-experimental study design was employed involving 300 healthcare students during June-August 2024. The study comprised 3 phases: a pretest to gauge baseline knowledge about UHC and PHC. An educational session focused on UHC and PHC was conducted, and a posttest to evaluate the knowledge acquired was done. The pretest and posttest consisted of a 23-item questionnaire. Statistical analysis comprised the Kruskal-Wallis and Wilcoxon signed ranks tests to compare pre- and postintervention knowledge scores.

RESULTS: The pretest results indicated a mean knowledge score of ±8.07. Following the educational intervention, the posttest results revealed a significant increase in knowledge, with a mean score of ±13.8. This positive outcome emphasizes the effectiveness of the educational intervention.

CONCLUSION: The study demonstrates that targeted educational interventions can significantly improve the knowledge of UHC and PHC among healthcare students. Incorporating regular educational programs, including practical seminars on UHC and PHC, in their study curricula is recommended to sustain and enhance this knowledge.